DBPR ABT-6008 Division of Alcoholic Beverages and Tobacco Application for Importer or Broker Sales Agent License STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION DBPR Form ABT-6008 Revised 02/2013 If you have any questions or need assistance in completing this application, please contact the Division of Alcoholic Beverages & Tobacco s (AB&T) local district office. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T s web site at the link provided below: http://www.myflorida.com/dbpr/abt/district_offices/licensing.html Importer Broker Sales Agent Transaction Type: Initial Permanent License Transfer of Ownership Correction SECTION 1 - CHECK LICENSE CATEGORY SECTION 2 - CHECK TRANSACTION REQUESTED Do you wish to purchase a Temporary License? Complete this section only if this application is for the transfer of an existing license Current Business Name: Current License Number Is this transfer due to revocation proceedings? If yes, is there any personal relationship to the transferor? If yes, explain the relationship: SECTION 3 - LICENSE INFORMATION If the applicant is a corporation or other legal entity, enter the name and the document number as registered with the Florida Department of State Division of Corporations on the line below. FEIN Number Business Telephone Number E-Mail Address (Optional) Full Name of Applicant(s): (This is the name the license will be issued in) Department of State Document # Location Address (Street and Number) City County State FL Zip Code Does the applicant entity currently hold any other alcoholic beverage license? If yes, complete the following information: License Number Series Type/Class Business Name Contact Person - This section is optional, see application instructions for details Contact Person Telephone Number ext. E-Mail Address Mailing Address (Street or P.O. Box) 61A-5.0015 FAC 1
SECTION 4 RELATED PARTY PERSONAL INFORMATION This section must be completed for each person directly connected with the business, unless they are a current licensee. 1. 2. Full Name of Individual Home Telephone Number Race Sex Height Weight Eye Color Hair Color 3. Are you a U.S. citizen? If no, immigration card number or passport number: 4. Home Address (Street and Number) 5. Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or tobacco products, or a bottle club? If yes, provide the information requested below. The location address should include the city and state. License Number Location Address 6. Have you had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit refused, revoked or suspended anywhere in the past 15 years? If yes, provide the information requested below. The location address should include the city and state. Date Location Address 7. Have you been convicted of a felony within the past 15 years? If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense 8. Have you been convicted of an offense involving alcoholic beverages or tobacco products anywhere within the past 5 years? If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense 61A-5.0015 FAC 2
9. Have you been arrested or issued a notice to appear in any state of the United States or its territories within the past 15 years? If yes, provide the information requested below and a Copy of the Arrest Disposition. Attach additional sheet if necessary. Date Location Type of Offense 10. Do you meet the standards of the moral character rule? 11. Are you an official with State police powers granted by the Florida Legislature? NOTARIZATION STATEMENT I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in the Disclosure of Interested Parties of this application. I further swear or affirm that the foregoing information is true and correct. STATE OF COUNTY OF APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this Day of, 20, By who is ( ) personally (print name of person making statement) known to me OR ( ) who produced as identification. Commission Expires: Notary Public (ATTACH ADDITIONAL COPIES AS NECESSARY) *Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes. This information is used to identify licensees for tax administration purposes, and the division will redact the information from any public records request. 61A-5.0015 FAC 3
SECTION 5 DESCRIPTION OF PREMISES TO BE LICENSED TO BE COMPLETED BY THE APPLICANT 1. Is the proposed premises movable or able to be moved? 2. Is there any access through the premises to any area over which you do not have dominion and control? If applicable, neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the premises, walls, doors, counters, sales areas, storage areas, restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show the details of each floor. 61A-5.0015 FAC 4
SECTION 6 DISCLOSURE OF INTERESTED PARTIES Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your license. You MUST list all persons and entities in the entire ownership structure. To determine which of those persons must submit fingerprints and a Related Party Personal Information, sheet, see the fingerprint section in the application instructions. 1. When applicable, complete the appropriate section below. Attach extra sheets if necessary. Title/Position Name Stock % CORPORATION List all officers, directors, and stockholders GENERAL PARTNERSHIP List all general partners LIMITED LIABILITY COMPANY List all managers (member & non-member), directors, officers, and members LIMITED PARTNERSHIP List all general and limited partners. LIMITED LIABILITY PARTNERSHIP List all partners Bar Manager (Fraternal Organizations of National Scope only): OTHER INTERESTS These questions must be answered about this business for every person or entity listed as the applicant 1. Are there any persons or entities not disclosed who have loaned money to the business? 2. Are there any persons or entities not disclosed that derive revenue from the license solely through a contractual relationship with the licensee, the substance of which is not related to the control of the sale of alcoholic beverages, or is exempt by statute or rule? 3. Are there any persons or entities not disclosed that have the right to receive revenue based on a contractual relationship related to the control of the sale of alcoholic beverages? 4. Are there any persons or entities not disclosed who have a right to a percentage payment from the proceeds of the business pursuant to the lease? 5. Are there any persons or entities not disclosed who have guaranteed the lease or loan? 6. Are there any persons or entities not disclosed who have co-signed the lease or loan? 7. Is there a management contract, franchise agreement, or concession agreement in connection with this business? 8. Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from any industry member as described in 61A-1.010, Florida Administrative Code? If you answered yes to any of the above questions, a copy of the agreement must be submitted with this application. The terms of the agreement may require the interested persons or parties related to an entity to submit fingerprints and a related party personal information sheet. Yes Yes Yes No No No 61A-5.0015 FAC 5
SECTION 7 APPLICANT ENTITY FELONY CONVICTION Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15 years? If the answer is Yes, please list all details including the date of conviction, the crime for which the entity was convicted, and the city, county, state and court where the conviction took place. (Attach additional sheets if necessary) SECTION 8 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED I, the undersigned individually, or on behalf of a legal entity, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a true and correct representation of the entire area and premises to be licensed and agree that the place of business, if licensed, may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the beverage and retail tobacco laws. I swear under oath or affirmation under penalty of perjury as provided in Sections 559.791, 562.45 and 837.06, Florida Statutes, that the foregoing information is true and correct and that no other person or entity except as indicated herein has an interest in the business and that all of the above listed persons or entities meet the necessary qualifications to be licensed as an Importer, Broker, or Sales Agent." STATE OF COUNTY OF APPLICANT SIGNATURE APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this Day of, 20, By who is ( ) personally (print name(s) of person(s) making statement) known to me OR ( ) who produced as identification. Commission Expires: Notary Public 61A-5.0015 FAC 6
SECTION 9 - AFFIDAVIT OF TRANSFEROR NOTARIZATION REQUIRED "I, the undersigned, hereby swear or affirm that I am duly authorized to make this affidavit and do hereby consent, on my behalf or on behalf of the transferor, to the above transfer, and represent to the Division of Alcoholic Beverages and Tobacco that the license which is being transferred is as shown in the application and that a bona fide sale in good faith has been made to the within applicant of the business for which the foregoing transfer of license is sought." STATE OF COUNTY OF TRANSFEROR OR AUTHORIZED SIGNATURE TRANSFEROR OR AUTHORIZED SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this Day of, 20, By who is ( ) personally (print name(s) of person(s) making statement) known to me OR ( ) who produced as identification. Commission Expires: Notary Public ABT District Office Received Date Stamp 61A-5.0015 FAC 7
SECTION 10- CURRENT LICENSEE UPDATE DATA SHEET This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date information is captured. 61A-5.0015 FAC 8